Abstract 12722: CABG Versus PCI in Patients with Diabetes: A Metaanalysis of Randomized Controlled Trials in the Era of Stents
Background: Despite results of recent trials, controversy still exists as to whether coronary artery bypass graft (CABG) surgery is superior to percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary artery disease (CAD), particularly in the setting of drug eluting stents (DES).
Methods: A systematic review and metaanalysis identified randomized controlled trials (RCTs) comparing CABG vs. PCI in diabetic patients with with both stable CAD and Post ACS, limited to RCTs where >80% were treated either with arterial conduits (CABG) or stents (PCI). Risk ratios (RR) and random effects models were used to pool results. Heterogeneity was expressed using I2.
Results: We identified 4 RCTs using bare metal stents (BMS) (ERACI II, ARTS, SoS, MASS II) and 4 using DES (FREEDOM, SYNTAX, VA CARDS, CARDia) enrolling a total 3612 diabetic patients. Mean age of mainly male patients was 60-65 years (y) with minimal left ventricular dysfunction overall. At 1y follow up, there was no difference in mortality, RR 0.99 (95% CI 0.72-1.37; p=0.97, I2=0%); however, by 5y follow up, CABG patients had lower mortality than PCI patients, RR 0.67 (95% confidence interval [CI] 0.52-0.86; p=0.002, I2=25%). Rates of repeat revascularization were significantly lower in CABG vs. PCI groups by 1y, and at 5y RR was 0.41 (95% CI 0.29-0.59; p≤0.001, I2=66%). There was no difference in pooled non-fatal MI rates but results depended on how periprocedural events were defined. Rates of stroke were higher in CABG vs. PCI after both 1y (RR 2.41, 95% CI 1.22-4.76; p=0.01, I2=0%) and 5y (RR 1.72, 95% CI 1.18-2.53; p=0.005, I2=0%). RCTs using BMS vs. DES showed similar results. Where heterogeneity was present, no clearly identifiable causes were identified.
Conclusions: We report the first metaanalysis of RCTs comparing CABG vs. PCI in diabetic patients in the DES era. CABG in diabetic patients is associated with an ~35% lower mortality and 60% lower rates of repeat revascularization compared to PCI with about a doubling in the risk of stroke. Importantly, these benefits are seen irrespective of use of BMS or DES. These data argue strongly in favor of CABG as the preferred strategy for revascularization in diabetic patients.
- © 2013 by American Heart Association, Inc.